Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 52 MOLLY TOWNE ROAD 4/30/2018
Air y i MATCH LINE DEP FILE#242-1296 J 4� �" t d °P° I LI ILI u•acP ORAw • °'n RIP~ I SEE SHEET 2 m / +d i+j61 wNt=xosvT nui:°wus +me" ,y '•,,� &—.. /� I G/B/ I /III INv trour-xw.m INv 1Yw•zwzv tyre tq ,,,per 'urxR nP•O J r NVM/trOM-MI ICB 1+) MEr /� I �I sED�IAI"�EM TION / G•'I(�/_ t��//. IIOIR=x°1AD N.xF o' a/i,oA coNmoLaluBrp s"T' i+'i 7/ LOT 12A oD-"o us -----------oFwomcXOU�SE t, w.tEsµDECD �Ory`°m tDBO 1^P wM.xoxve °"'�x _______}_telNO�yn co- IlN1SOUF.x0121 c, u TOP2 1+FNq 'P 4 a ,oe w e1 I ' `A._p S p iNI 4?& 1 �Y/ 4 I e•tlDl Qp I p 103 � i/ ��/ WATERM.VN ^I�• LOT 11 a Pvc ae ea / STORAGE AREAS:DETENTION POND#1 A i a3(�..—� / / NIF HOUSE ELEVATION(m.)DESIGN SURFACE—(SFl ASBURTSVRFACEAREA(SFt ' �4` LOCUS MAP NON- GSNP.ANDOVER e31 OO°E'OpF n "INS ta.iN 'O .I' tam. tw '+*CS .0 ./i�'D /1J/ll•/f9-- TOPFND. PAVES WF +ie tT.a35 1>a90 a • (TYP•) BVSANLEIOURNGV NOTE.TIEt /' W YEAR PEAK STORAGE EIEVATON:t]eA Ff. LEGEND ax r// • R-4 StDIM.NTAl10N FFE"'///� /f' TOp p �ys5 SMN NF NOWORFORMER6YOF a.a OMR / A�///�, y INVxD'V#'OiLll.t)eAe OF WORK a1 / yfa•/,/Nep'/fir ve0 � iI j I �H°ll�"9E° +a p ® DPAIN MANHOLE ADCEsea LOT 10f 11 GTLH BABM AND OHMAGE PPe �/ �I 111 O�ypAE"F WSW.%gyp TO1�D FIARE°END eELTONd RIRRAP A9 I l!l prg 11 I I '� III PIieI.tt COpP. • z 19 FWEHYOR— ll!f l/i/pIQ(1, i I LOT 5 LOT 4 WATE MA Na DATE VALVE 1 II 111 DN I I O BwwnroN IIIF YF— wATEReERVICEsxur-0FFVALVE I Ijlll j)11' PONDM#1 1111 I— SIBS XERNMD W! /11 I III $ If, �•' m— BEWFAMANXIXea6ENi]IMAM &—Qm IkT I' �� NP.RAP 1I1113 LOTS ODBIwO ! J E%Is11N: l'G-- 6EW9tSERNCESNB xe @ I Jit, SII xva ;I I y1 xousE O xousElm p°EpN° LOT 3 ° —mN o �� ILII I�I+ Q 'I I Ijl MAmmE"V/RET69 1°' � roPFN4 XOVSEIl/ —Wv— IIImERGIiO1M0 EIEC,RICRELEPHONENAOIE ry I.tE' a12s roPFnv. NT 1 ' I -x9dJ DSK9AMEMIi(REAI.TYTR114T � E]OBIINGEDGEOFPAVEAIENf N� (/ \ �1I 1 II roPRiD. SA91 ceeNBL ORATE) I\ 1 I IMI •x,e.19 NM•20720 1 I11\I�\ NX FG�REsw dill xroRAHr ;ar Irrvour.xm.m e•wcsEwEa --+m-- �( ` I E%ISIIN°ELEVATION OIXtIOUR t� EpSTMp �.�...— WERANO FIA°MIDEOOE OFDOMMINO �\ 1.1�\\\\\•(al trra e'PVC6EVAT WATER ) HOE FFV619 LMROFIWBUFFERIDNE — 'x' ` 1YRCPOMM —m LMRORRI'NOaIIM ZONE \\\\\\\aa , + I 21—P-Inn LOT 6 " SNN —>♦— \a\\`tlov ISPOMXe LMROFx3•NOOI°TURSIDNE \ x1'CPPOMIN HENNYMIIOHEtt TOPFND. WM•ZmA1 / 9MH 9PV09EWER LOT BEDMEMATONCONTROL EAPRIEM x0� •x1Sz1' 9MH INV_-x01.] BOmR°DWlva I a E \�A mI.-I 1 INVOUI'•xNdB Eb°sEMO �eer BERNCE9N0[TW.7 DOSIING JEaEx,v lnuAm --- I.MROFWORK VEGETA 1v . ON u•w•1N.ee L9e Cal PAVEMExr(IVPJ �1 XOV6E M'EItANO � I PROF 1 I DNNOUY•17PEe PIM-IDA11 �.101�1 ,eg: A I RK I I INv+rour•+BnaD ,z0 F Q I ;?�^ BARK MIACHEO ,�.� / S IANOSCAPEAREAxxe8 10 d PAVEA6 LOT7 �sp� °Msx011a NM•CB2�Be.a9°�� ,0/ F / I I HWBE IHV it 1X•18821 New e) NV iTOUT•�G,ta I I +e INv+zw•+wevtce e) °��� mt°unn� TOPq mis•DI"u'rvie�e.+o°Bn �t snit "ISR'N�6 1 CNRF BCORUNOER6 • DRAIN RCP M vow e•CLOI BATIwOl PRO11N0 RA°, �x00d0 RNIYOUT•xN.O WATER MAIN I yNECAGB WT+x C(iV9HED 1 •18e.18 6 � MMR OF 100' I STONE BORDER 9MH INVfYOUT•Me.N OA01t WSPPIRwN OPEN SPACE BLOT 1 -_IN (-2) °03PO I FJDsrero ISM-1 ]x - m pICAR.m PLAN OPEN SPACE A HOUSE INVtr III—M TOP FND. ISo LOT 6 nn INvtr ou.1— sew =znze na o 4V So- 19WIOeACCE99 I I e NRMN ORRIS TOP FMI 1r MPDRAIN HYDRANT P ..")AOE I -2ozm SCALE:1'-4U EAREMEN! I I tx OHnISTIANGENa SER I i p1PRMV°OMOE e•wcsEwEa "-e,Nm IMrPM/+w-i2am New+) 1raeP DluR+ ISMa SHEET OF DMHB I I EMFM RNNPIN-lee P 4) INVtYW1eaN1C801 CONSERVATION AS-BUILT PLAN INV+Y IN•+BEW IOMX ea) PNIYIN•12e.Y LCB a) NAL mM•tee.ix _____ _______---------_---- INV 16'M•100]B(DMHT) INV 1Vo, 1-1 FOR ENGI—NEE INV191N=1mAe INV 1901If-1ee]3 IxV2AOUf•IDL,e I �___ __—__CROSS-0OIINTRV DRAIN'C•______ 16.CPP opt WmDE _�� "AUTUMN CHASE" / I 1 1SircORMrt N °RW�1m2T OMeMd-+ DG. � — ' �— alb _ 8 I DN16•M•18eN 1=wm ,m T�— 16.OpPOPN �� ' OB (MLORATE] NORTH ANDOVER,MASS. e9e(GeL GRATE) Ixv trour-+m2e ,,�— wM•mxve aM•fDxztIxv tz Dur•twze INv,r°vr•tev.M •/: �_ APPuaur: _ °Be NORTH ANDOVER REALTY CORPORATION # IaOS�UMpY IxvM>rR°tTJ ee eMH 13'CPP DP/0N � OVi•+08.88 SPRING MU RHD,NORTH ANDOVER,HA wete eNH _ LIP q CHR18TAxsEx,P.E 1"7ES6 6MH SUMMER STREET PROF10.1. 01111ERSdUNDSURVEVORS DATEIA,LY,e.xw: RM•,al2l CHRISTIANSEN&SERGI INC. "�"""°'°"•'" MV,Yw•tee.oDNee) casNel_oRATt� IW tS.0-tN.eetCB% _M-19LT5 AVERMLL MA58Af E�io33 ebb° INV 16'OVT•teaT4 INV IY OUT-1e8.OD M•TEL VTesTSPTIv DVAD.Nq vTOeeDxe Date . . � . . . . . �. Irv. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . k.Q c j 7p;.�"�-j. Z t! . has permission to erform '. N� !!Vlvv :--- . . . . . p . . . wiring in the building of J at . . . �. . . !"! �. .1 .�� . (24, . ,N Andover, Mass. Fee .0.q. . Lie. No. Z $ . . D. . . . V' ELECTRICAL INSPECTOR r eTeck# 11219 ` Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL) FORMATION) Date: / /�-. owl 2- City City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the elec 'cal work described below. Location(Street&Number) Z9:2� A1// Owner or Tenant (?A v Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service 0Amps ,`eJ/ Volts Overhead❑ Undgrd No.of Meters Number of Fee ers and Ampacity Location and Nature of Proposed Electrical Work: 41,2-1,oa aA Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires sd No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o-FEmergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 60 No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burners No.of Detection and 25 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste DisposersHeat Pump Number I.Tons KW No.of Self-Contained 1 Totals: ................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent " OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pal s andpenalties of perjury,that the information o tlti I' ' n is true and complete. FIRM NAME: . i LIC.NO.: C 7Pgp -- Licensee: 4 e,' ,'�yd/`L/i Signature ? LIC.NO.:a aW-Z - (If applicabl inter "exem t"in the license numbe line.) Bus.Tel.No.. ASI-L4 9/ Address: � �/1�(/yi ,ry Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departmen of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. i ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed J on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, §32,an $ �I electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date:L1 /Z SERVICE INSPECTION: Pass • Failed Re-Inspection Required($.) El Inspectors Comments: Inspectors Signature: Date: 1 PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: j ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors C nts: r �^ Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction r employees(full and/or part-time).* have hired the sub-contractors 2:❑ I am a sole proprietor or partner- listed on the attached sheet. I E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]I employees. [No workers' comp.insurance required.] 13.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ]Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. F am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: lob Bite Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 'me up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine )f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 'ignature: Date 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if r. necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should e returned to the city or town that the application for the permit or license is being requested,not the Department of �- `austrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. f Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant G that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia t No 9651 Date.l' . . . NORTH .'h, TOWN OF NORTH ANDOVER i R PERMIT FOR PLUMBING Rizizwi �-Is musE� , This certifies that . . . .W. . P 1I8!. . . !. . `G 1 has permission to perform1 . . ....ea plumbing in the buil Ings of . . . . . . . . . . . . . . . . . i� . : . at. era,` , North Andover, Mass. t Fee 44. . . .Lic. No.��J�h7. . . . . . . 3 LUMNSPE OR V� Check # PBING I WHITE: Applicant CANARY: Building Dept. PINK:Treasurer f v y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY (�_ I MA DATE� ]PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS _ j TEL FAX I TYPE OR OCCUPAN Y TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: I RENOVATION:© REPLACEMENT:0i PLANS SUBMITTED: YES NOD[ FIXTURES 7 FLOOR- BSM 1 2 3 1 4 1 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ( _-___! ._,.._-_J i - ----------_._._.-_1 ...____1 .___-_[ .......... DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _....J FOOD DISPOSER I _ [ -.-___i _--.._J __...... J [ .__-_--J __..__.J -__---_( ! ._....__J ._.--_I . _J ( .- FLOOR AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I _ .-._.► - -_.__1 _._.—[ _-____f _.___-_1 __._._( _._..__1 _.._.-__! ..---_.-.J _:___._-.-{ __.._..__[ ^I _ _.[ ROOF DRAIN ._.._l ___--► ----_-_I -_-� .._..___f 1 { J .__. J ..____._.f SHOWER STALL SERVICE/MOP SINK _._.__I { TOILET [ ._.._ ._I _[ I _.-_..J _ .__. J J __.._t URINAL -...._J, F WASHING MACHINE CONNECTION _. I I .. ! - i I _. I I l . [ J J i WATER HEATER ALL TYPES WATER PIPING OTHER _ I __.I 771 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 5 NO .- ! IF YOU CHECKED YES,PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BONDI OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Q AGENT JEJ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provisi n f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME +f , LICENSE# /,SAF SIGNAT RE MP 5� JP P CORPORATION 0# _- - �PARTNERSHIP P# LLC COMPANY NAME - ; ADDRESS i CITY1 PtJ" j STATE ZIP b D'� �o TEL FAX CELL gMAIL �� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIONANOTES Yes No .f 71/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES y fr R r r The Commonwealth of Massachusetts 02 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. # 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. [do hereby certify under thej2ains and penalt' of ury that the information provided above is true and correct. Si nature: Date: Phone#: M Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A � r ff Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia i °. :COMMONWEALTH OF MASSACHUSETTS '. PLUMBERS AND GASFITTER, . LICENSED AS A-MASTER PLU'MEEFc_ ! ISSUES,THE ABOVE LICENSE TO: ICNA.E.L.. 4�1 KELLEFz 20' Kt`IVN.EDY f. `PE-L'HAhi' NF{ 030.7.6—.2605 ->151�7 05/01/1:4• Y J X ti Y JI - 1 I r i I a; CONTROL# H 3 8 2 6 8..G IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 1000 Washington St., Suite 710;Boston,MA 02118-6100. If your name or address shown is changed, notify your board of correct name or address to insurq proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended. It is a personal privilege,and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 562,500.00 m $ - $ 6,750.00 Plumbing Fee $ 843.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 843.75 Total fees collected $ 8,537.50 52 Molly Towne Road 813-12 on 5/11/2012 New Single Family Date I�. h l I' bw�tLED 7 ll TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . has permission for gas install ion in the of s building . . .IV A ` . . . . . . . . . . . . . . . . . . . . . . . . at . . . .b. .. .f'.'U :�A.0 , North Andover, Mass. Fee .I CQ..C�0 Lic. No. P'161 A . . . . . . . . . . I . . . . . . . . . . . . t GASINSPECTOR Check# 1T 8414 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYMA DATE PERMIT# 4 - - JOBSITE ADDRESS / OWNER'S NAME y � -- - GOWNER ADDRESS T _ _ TE — FAX�-- TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL i PRINT CLEARLY NEW:Ne",RENOVATION: REPLACEMENT:- PLANS SUBMITTED: YES EJ NO[_I APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER .J .—._I �I COOK STOVE .... I� �.-:.�:_� >,.I. DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE J GENERATOR _ _._I I_�__. _f �._I I _ I ! 1 __ _. - �- ___J I� I _ _► J ._-�._! _=_f GRILLE _:.- INFRARED HEATER LABORATORY COCKS -.--1. MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _-- -- -- ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER IE _ _ 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J[j�rNO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d OTHER TYPE INDEMNITY Q BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit all ertin`�sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE -GASFITTER NAME _ LICENSE# - SIGNATURE MPMGF .__-( JP __._.l JGF LPGI ! CORPORATION # PARTNERSHIP _.i �J CI -� fD#=LLC M# COMPANY NAME: 21i]/ ( _-- µ :.-_---11 ADDRESS MA 0 CITY STATE ZIP TEL FAXCELL '7wMAIL --- - - - ROUGH GABS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPE!MON1,VOTES — Z Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ily FEE: $ PERMIT# PLAN REVIEW NOTES is The Commonwealth of Massachusetts rn Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: d Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13T] Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certify under the pains and pe alt' f perjury that the information provided above is trite and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: a, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia ' 1e+ i s -COMMONWEALTH OF MASSACHUSETTS 77 PLUMBERS AND GASFITTERS. LICENSED AS A MASTER PLUMBER ISSUES:THE ABOVE LICENSE TO: "lLGNAEL V1 KELLEK 20 KENNEDY DFS;' PELHAhi` ' N.� ? G.30.76.—„AGO.,.. 15,157 l�5/U'L!).k 1.74161 ,r